A 32-year-old man weighing 209 kg and suffering from severe obesity underwent a successful bariatric surgery at AIIMS here after doctors first helped the patient, whose abdominal girth of 198 cm was too large for the standard operating table, lose weight, doctors said on Thursday.The doctors stabilised his breathing over more than a month before performing an emergency tracheostomy on the patient’s bed inside the operation theatre before preparing him for the weight-loss surgery, Dr Manjunath Maruti Pol, professor in the Department of Surgery at AIIMS, said.After treatment, his weight has been reduced to 160 kg.”This case demonstrates that pre-op multidisciplinary optimisation with VLCD and airway stabilisation can transform an otherwise inoperable patient with super-super obesity into a suitable candidate for bariatric surgery,” Dr Manjunath said.The doctor said the patient, who is from Karawal Nagar in Delhi, was referred for bariatric surgery after his weight increased steadily over the years.At his first consultation, he weighed 181 kg with a BMI of 64. The patient delayed his decision on surgery by about a month, during which his weight rose to 209 kg, his BMI reached 74 and his abdominal girth increased to 198 cm, Dr Manjunath said.He also suffered from severe obstructive sleep apnea, hypertension, prediabetes, dyslipidaemia, gastroesophageal reflux disease, depression and bilateral knee pain, Dr Naval Vikram, professor at the Department of Medicine, said.Before surgery, his respiratory condition worsened and he was unable to maintain oxygen saturation despite continuous positive airway pressure (CPAP) support, he said.Doctors first inserted an endotracheal tube and later performed an emergency tracheostomy as prolonged ventilatory support was anticipated.”Because of his extreme body habitus and abdominal girth of 198 cm, the patient could not be accommodated safely on the standard operating table.”Consequently, tracheostomy was performed as the patient was not maintaining blood oxygen levels even on CPAP. Therefore, tracheostomy had to be performed on the patient’s bed inside the operating theatre,” Dr Manjunath said.The patient remained dependent on CPAP through the tracheostomy for 32 days while being treated by a multidisciplinary team comprising bariatric surgeons, anaesthesiologists, pulmonologists, intensivists, nutritionists, psychiatrists and physiotherapists, Dr Sulagna Bhattacharya, associate professor at the Department of Anesthesiology, said.During this period, he was put on a 32-day very low-calorie diet (VLCD), respiratory physiotherapy, infection control measures and nutritional counselling, Dr Richa Jaiswal, senior dietician AIIMS, Delhi, said.The treatment reduced his weight from 209 kg to 172 kg and brought down his abdominal girth from 198 cm to 178 cm, enabling doctors to safely position him on the operating table using side-table extensions, Dr Vikram said.”Perhaps the most striking observation was the substantial reduction in abdominal girth (198 cm to 178 cm) after only 32 days of VLCD. This reduction was clinically more important than the absolute weight loss because it permitted safe positioning and improved respiratory mechanics,” Dr Manjunath said.Doctors performed a laparoscopic One Anastomosis Gastric Bypass (OAGB) on July 24, completing the procedure in two hours and 10 minutes without any major complications.Doctors said the patient’s respiratory support was gradually reduced to 160 kg after surgery and by the 13th post-operative day, he was breathing independently, walking on his own, had resumed self-care activities and reported a significant improvement in his quality of life.His abdominal girth had further reduced to 155 cm.”Super-super obesity associated with prolonged CPAP dependence and tracheostomy should not be considered an absolute contraindication to bariatric surgery. A structured multidisciplinary optimisation programme incorporating prolonged VLCD, respiratory stabilisation, nutritional support, and meticulous operative planning can safely bridge such patients to definitive metabolic surgery,” Dr Manjunath said.The patient said he had gained a significant amount of weight over the last four to five years, making even routine daily activities such as walking increasingly difficult.He said he spent most of his time sleeping, developed severe breathing problems and continued to gain weight. He also said he had a habit of overeating and was on medication for depression.”Earlier, I could hardly walk and even simple activities were a struggle. Now I am able to walk again. The doctors have told me that with continued weight loss and follow-up, my weight could eventually come down to around 70 kg,” the patient said.